Roth Net Assisted Stone Removal via Direct Cholangioscopy

Abstract

Purpose: Around 90% of extrahepatic bile duct stones are treated with endoscopic sphincterotomy followed by stone extraction, while others require additional intracorporeal lithotripsy for complete stone removal. Direct cholangioscopy (DC) with a mother-baby endoscopic system assists in visualizing and removing difficult to extract common bile duct (CBD) stones, but is limited by inferior optics, narrow maneuverability, and restrictive therapeutic applications from its small working channel. Furthermore, the procedure has poor visibility in dilated ducts, is time consuming, and usually requires the presence of two skilled endoscopists. SpyGlass® cholangioscopy (Boston Scientific) eliminates the need for a second endoscopist but much of the other limitations with the mother-baby endoscopic system remains. A 77 y/o male with a Billroth II for peptic ulcer disease underwent emergent endoscopic retrograde cholangiopancreatography (ERCP) with a limited papillotomy and stent placement for cholangitis. One month later he was re-admitted for elective cholecystectomy and ERCP with CBD stent and stone removal. ERCP with a pediatric colonoscope was initially used to traverse the afferent limb and the previous sphincterotomy was extended via needle knife and dilated up to 18 mm with a 15/16.5/18MM CRETM balloon dilator (Boston Scientific). Multiple balloon sweeps were performed with removal of two stones but a possible third retained stone was seen. The colonoscope was removed and an adult Olympus G-160 gastroscope was successfully passed via afferent limb into the ampulla and CBD where a CBD stone was identified. A Roth net was used to successfully retrieve the stone from the CBD, with DC up to the hilum showing no other additional stones. DC offers direct visualization of the biliary tree for diagnostic and therapeutic interventions, such as treatment of intraductal papillary neoplasm of bile duct, APC of recurrent hepatoma and intraductal growth, and EHL for difficult biliary stones. DC has typically been described using small-caliber endoscopes, with tandem endoscopy in intact gastrointestinal anatomy. Here we present a patient s/p Billroth II who underwent single-step DC with an adult gastroscope, with a novel form of CBD stone retrieval via a Roth net.Figure: [206]Disclosure: Dr. Kim - Consultant: Boston Scientific, Speaker: Gilead.